Provider Demographics
NPI:1780816314
Name:KOSHY, SHINTO JACOB (MD)
Entity Type:Individual
Prefix:DR
First Name:SHINTO
Middle Name:JACOB
Last Name:KOSHY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1041 E YORBA LINDA BLVD STE 210
Mailing Address - Street 2:
Mailing Address - City:PLACENTIA
Mailing Address - State:CA
Mailing Address - Zip Code:92870-3763
Mailing Address - Country:US
Mailing Address - Phone:818-386-6358
Mailing Address - Fax:714-223-7000
Practice Address - Street 1:1041 E YORBA LINDA BLVD STE 210
Practice Address - Street 2:
Practice Address - City:PLACENTIA
Practice Address - State:CA
Practice Address - Zip Code:92870-3763
Practice Address - Country:US
Practice Address - Phone:818-386-6358
Practice Address - Fax:714-223-7000
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-15
Last Update Date:2021-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA139304208VP0014X, 208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty